Organisations. registered charity no England & Wales registered charity no ; Scotland registered charity no. SC041666; Isle of Man

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2 Organisations Cancer Research UK 1 Every year around 300,000 people are diagnosed with cancer in the UK and more than 150,000 people die from cancer. Cancer Research UK is the world s leading cancer charity dedicated to saving lives through research. Together with our partners and supporters, our vision is to bring forward the day when all cancers are cured. We support research into all aspects of cancer through the work of over 4,000 scientists, doctors and nurses. In 2011/12 we spent 332 million on research. The charity s pioneering work has been at the heart of the progress that has already seen survival rates in the UK double in the last forty years. We receive no government funding for our research. Institute of Physics and Engineering in Medicine The Institute of Physics and Engineering in Medicine (IPEM) is a charity which aims to promote for the public benefit the advancement of physics and engineering applied to medicine and biology and to advance public education in the field. It also fulfils many of the roles of a learned society. It publishes world-leading scientific journals and books. It organises scientific meetings and conferences to disseminate knowledge and support members in the continued development of their skills and understanding. It sets and advises on standards for the practice, education and training of scientists and engineers working in healthcare to secure an effective and appropriate workforce. The Royal College of Radiologists The Royal College of Radiologists (RCR) has over 9,000 Fellows and members worldwide, representing the specialties of clinical oncology and clinical radiology. The RCR sets and maintains the standards for entry to and practice in the specialties in addition to leading and supporting practitioners throughout their career. The Society and College of Radiographers The Society of Radiographers is the professional body and trade union representing the professional, educational, public and workplace interests of the entire radiographic workforce in the UK. The College of Radiographers is the charitable subsidiary of the Society, with objects directed towards education, research and support of the science and practice of radiography. Together, the Society and College develop standards and policies for radiographic practice that are regarded as world-leading. We champion partnership and interdisciplinary work for the benefit of the public. We lead in developing new ways of working and ensure that imaging and radiotherapy professionals work in a safe and fair environment. 1 England & Wales registered charity no ; Scotland registered charity no. SC041666; Isle of Man registered charity no

3 Contents Executive summary p.4 1. Background and introduction p.8 2. Detail and aim of the Fund p How the Fund was allocated p Impact of the Fund p Additional benefits from the Fund p Remaining challenges for the NHS p.29 in provision of advanced radiotherapy 7. Conclusion and recommendations p.33 Appendix 1: Radiotherapy Centres IMRT p.36 delivery and radically treated patient numbers Appendix 2: Methodology p.39 Appendix 3: Action Plan and funding request p.41 Appendix 4: Approving funding p.43 Appendix 5: Possible items for inclusion p.45 in funding requests Appendix 6: NCAT training programmes p.48 3

4 Executive summary The Radiotherapy Innovation Fund marks a step change in the delivery of advanced radiotherapy in England. Without this Fund it is highly unlikely that centres across the country would be able to meet the minimum standards for Intensity Modulated Radiotherapy (IMRT) within the NHS England service specifications. In addition, the Prime Minister s personal pledge that all patients will have access to the most appropriate, safe, and cost effective radiotherapy that their doctor recommends would not be achieved. In August % of patients receiving radiotherapy in England were given IMRT. By April 2013 this figure had risen to 22.3% 3. This means that around 5,800 more patients a year across England will now have access to advanced radiotherapy treatment, which is more targeted at the patient s cancer and causes less damage to surrounding healthy tissue. This clearly demonstrates the immense value that the Fund has brought to radiotherapy services, and will continue to bring as the full benefit of the additional resources is realised over this year. The expectation for all Trusts to achieve 24% IMRT by April was recognised by all as highly ambitious. While not all centres met this level, considerable progress has been made in a very short period of time. Much of the Fund was used to purchase software and equipment which carries with them a lead in time due to commissioning at the hospital site before safe clinical use, and so we expect to see further improvements as these are utilised. The success of the Fund can be attributed to a number of key factors: 1. A personal commitment from the Prime Minister on radiotherapy. 2. Constructive collaboration between the Department of Health, Cancer Research UK, the Institute of Physics and Engineering in Medicine, the National Cancer Action Team, the Royal College of Radiologists and the Society and College of Radiographers to design a process which allowed money to be targeted on the basis of need and opportunity, and supported a case for additional funding over and above the original 15million commitment. 3. A pragmatic approach from the radiotherapy community, NHS Supply Chain and manufacturers to work to the very tight timescales and conditions placed on the Fund. 4. A dedicated professional approach by clinical radiotherapy teams to ensure software and equipment funded by Radiotherapy Innovation Fund was, and continues to be, implemented as a priority in a safe and effective manner. 5. Support provided by National Cancer Action Team and clinical members of the National Radiotherapy Implementation Group to run 46 challenge sessions across the country to help centres submit robust applications and ensure that the Fund achieved the best value for money and impact possible. The ramp up in IMRT that has been seen would simply not have been achievable without the money which the Fund provided. Years of incentives and targets, but without additional ring-fenced funding, have failed where a relatively modest investment in the service has now shown success. The Radiotherapy Innovation Fund was absolutely critical to fill a gap in the radiotherapy service that should not have existed. Significant challenges remain. The radiotherapy service will continue to need to introduce new innovative radiotherapy treatments, as they are evaluated and developed. Experts now believe that the goal for delivery of IMRT activity is likely to be around 50% for all 2 Data for 4 centres was only available for November 2012 (prior to the implementation of the fund) and has been assumed to be representative of IMRT delivery at those centres at this point in time. 3 Based on self-reported proportions of radically treated patients receiving inverse planned IMRT in these periods, and the number of radically treated radiotherapy patients in FY 2012/2013 at each of the centres in England. 4

5 radical radiotherapy patients 4. The introduction of a tariff and changes to commissioning structures will go some way to support improvements. The funding and roll-out of advanced radiotherapy and innovation should be a priority for NHS England, to ensure patients have access to world class radiotherapy. Given the impact that radiotherapy can have in curing cancer and reducing the premature mortality of patients who receive it, continuing commitment is vital to ensure that patients across the country are given access to the best possible radiotherapy service, regardless of where they live. Recommendations In reflecting on the success of this Fund, and the size of the challenge still to be met in radiotherapy, there is a real opportunity in the NHS in England to continue to build a world class radiotherapy service. To achieve this, a number of measures need to be taken: Funding NHS Trusts, with support from Government, must urgently find a solution to the current challenge in providing sufficient numbers of up to date linear accelerators. Individual providers are responsible for maintaining and replacing high value equipment. Trusts need to prioritise their investments and ensure that they have sufficient equipment to provide high quality, safe and cost effective services for patients. They should also work with NHS Supply Chain on the procurement of radiotherapy equipment to make full use of the 300million capital equipment fund. The association between delivering advanced radiotherapy and the tariff, and the consequences of not providing these facilities, needs to be the responsibility of the highest management levels within Trusts. Government should consider additional ring-fenced funding streams to further boost radiotherapy services in the future. Radiotherapy is clinically cost effective. It accounts for 5% of the national spend on cancer, yet is second only to surgery in its effectiveness in treating cancer. The 23million investment through the Radiotherapy Innovation Fund is relatively modest, especially in comparison with funding provided to other areas of treatment and in promoting innovation in the NHS. Pound for pound, the number of people likely to benefit from this fund is highly competitive with other areas of investment. Given the success of this Fund, future one-off ring-fenced investments in radiotherapy should be considered. Service delivery and commissioning NHS England should provide support to ensure the roll-out of Image Guided Radiotherapy (IGRT). While progress is being made, more effort is needed to ensure that all patients who might benefit are being offered this. The national support programme for IGRT and the introduction of a CQUIN for IGRT in 2013/14 will go some way to address this, but progress will need to be closely monitored. This will be crucial to making progress on the NRAG 2007 recommendation that all centres should be delivering 4D adaptive radiotherapy as standard. 5 A 4 T. Cooper, M.V. Williams. Implementation of Intensity-modulated Radiotherapy: Lessons Learned and Implications for the Future. Clinical Oncology 24 (2012) National Radiotherapy Advisory Group, Radiotherapy: developing a world class service for England (2007) 5

6 progress report from the National IGRT programme will be published in summer 2013 with specific recommendations for further supporting work. The Radiotherapy Clinical Reference Group should ensure specialised commissioning includes incentives to promote improvements in radiotherapy. From April 2013 radiotherapy is being commissioned nationally as a specialised service. This is a positive step forward for the radiotherapy service. Until recently, local commissioning arrangements varied hugely across the country and were often not sufficiently flexible to reward complex or innovative radiotherapy practice. The service specification for radiotherapy should aim to promote best practice and, where appropriate, stretch the radiotherapy service to provide world-class treatment uniformly across the country. Providers will need to be given an appropriate level of support from commissioners to meet these specifications. Implementation of the national tariff for radiotherapy should be monitored by NHS England to ensure that it is fit for purpose and is flexible enough to include new treatments as evidence supports their introduction to the service. Historically, radiotherapy services have been commissioned using locally agreed tariffs via block contracts. This has resulted in different contract types and a variety of currencies and prices across the service. While it is accepted that there will be winners and losers across the country as the national tariff is introduced from April 2013, the impact of the tariff should be subject to close scrutiny. This should provide incentives for radiotherapy and promote innovation. Innovation and workforce Processes should be introduced to support innovation in radiotherapy. NHS England and the Clinical Reference Group should investigate an appropriate long term solution for ensuring innovative radiotherapy treatments are rolled out across the country as soon as possible. The service specification for radiotherapy, and the additional support provided by the Radiotherapy Innovation Fund will help the roll-out of advanced radiotherapy. However, both of these mechanisms are focused around the minimum standards for advanced radiotherapy that each centre should be meeting now and not targets for the future. It is likely the 100million NHS England Specialised Service Commissioning Innovation Fund will be stretched across the whole of the NHS. Individual treatment requests are arduous and not appropriate for treatments that have proven clinical benefit in the significant proportion of patients who receive them. A long term solution is needed. NHS England and Health Education England should take action to address current shortfalls in the radiotherapy workforce to ensure continued improvements in advanced radiotherapy. A plan should be put in place to ensure that the skills and resources required to meet future demand, and the introduction of innovations to radiotherapy services, can be achieved. The ongoing introduction of new technologies requires additional time during the implementation phase, and all these new technologies demand additional workforce skills and require longer time to undertake compared with previous treatments. Additional workforce is required to support this effectively. Services should map skills requirements to patient pathways to ensure existing resources are used effectively and efficiently. Services should also ensure that new workforce resource is planned for to enable the right levels of advanced radiotherapy to be delivered to patients across England. 6

7 Data and monitoring Progress in the delivery of advanced radiotherapy should continue to be monitored through the Radiotherapy Dataset (RTDS). The National Cancer Services Analysis Team (NATCANSAT) should undertake further work to ensure effective monitoring of each specific element of radiotherapy, and have clear criteria for unambiguous data entry as it is developed. While the past three years have seen progress in the completeness of the radiotherapy dataset, coding issues mean that providers self-reported activity is still at odds with that reported in the radiotherapy dataset. We recommend greater granularity within the coding of the RTDS to enable the data from centres to enable accurate monitoring of the levels of specific types of advanced radiotherapy across England. The RTDS should be used to populate the commissioning dashboard and enable monitoring against the service specification. Ensuring the RTDS is populated with the correct data will remove the requirement for centres to self-report for specific data sets. The Radiotherapy Clinical Reference Group should develop appropriate metrics to measure both the quality and quantity of radiotherapy. The Group should regularly monitor progress in the delivery of advanced radiotherapy including IMRT, IGRT and SABR. Historically the radiotherapy service has been rated by the number of fractions delivered and patient throughput. Priority should instead be given to quality measures such as the number of patients receiving advanced radiotherapy and the quality of the components of the process such as imaging and planning to deliver advanced radiotherapy. Delivery of advanced radiotherapy should be monitored against the national service specification, using the RTDS and commissioning dashboard, and compared to patterns of local delivery. The CRG should ensure that the appropriate percentage of patients and diagnoses have access to advanced radiotherapy, and if necessary re-direct patient flows to centres that can deliver such quality and capacity. 7

8 1 Background and introduction Radiotherapy can cure cancer. Experts suggest that radiotherapy is second only to surgery in its effectiveness in treating cancer, and around 4 in 10 patients whose cancer is cured receive radiotherapy as part of their treatment 6. Radiotherapy treatments have become significantly more sophisticated in the last decade and can deliver more targeted treatment. These advanced radiotherapy treatments can improve outcomes and reduce highly debilitating side effects. Advanced radiotherapy therefore plays an important role in contributing to Domains 1, 2 and 3 of the NHS outcomes framework (preventing premature mortality, enhancing quality of life and helping people recover from episodes of ill health). In October 2012, the Prime Minister and Secretary of State for Health announced the establishment of a Cancer Radiotherapy Innovation Fund. Initially set at 15million, it was later boosted to 23million. The Fund was introduced to support the roll-out of advanced radiotherapy treatment across the NHS in England. The main aim of the Fund was to ensure that all radiotherapy centres could deliver a minimum of 24% of all radical treatments using inverse planned Intensity Modulated Radiotherapy (IMRT) by April 2013 or as soon as possible thereafter. 1.1 Why IMRT? IMRT is a more targeted form of radiotherapy. It is used in some cases due to the limited ability of conventional radiotherapy to avoid vital organs and confine dose within the tumour region. IMRT shapes the radiation beams to closely fit the shape of the cancer and alters the radiotherapy dose accordingly. This means that the intended target volume receives the highest dose of radiotherapy and the surrounding area of healthy tissue gets lower doses. IMRT, along with other forms of external beam radiotherapy, is given using a linear accelerator machine (linac) which uses electricity to create the radiotherapy beams. Inverse planned IMRT Inverse planning is very complex and allows for the generation of a treatment plan that uses a large number of segments (beamlets) automatically. This is done by defining a number of objectives (for example, maximum dose allowed for a vital organ) that the plan must satisfy. These are then used to optimise the plan automatically to target the tumour and minimise the dose to surrounding healthy tissues. Calculated by a computer, an IMRT plan performs three trillion individual calculations. Inverse treatment plans can take longer to produce and can take up quite a lot of skilled resources. A treatment plan is created for each patient receiving radiotherapy. The type of plan created is dependent on the type of tumour and what kind of radiotherapy is being delivered. IMRT treatment plans can be created using two methods: forward 7 and inverse planning. Increasing the number of patients receiving inverse planned treatment was the focus of the Fund. When IMRT is mentioned in isolation in this report, it is referring to inverse planned IMRT only. 6 Department of Health (2012). Radiotherapy services in England Forward planning is an extension of conventional treatment planning used for relatively simpler cases. Using this method segment shapes and weights are defined manually by the treatment planner to produce a suitable dose distribution. The number of segments created using forward planning is considerably less than inverse planning. 8

9 A new guarantee for cancer patients In announcing the Radiotherapy Innovation Fund, the Prime Minister also introduced a new guarantee for radiotherapy patients. This extends the existing guarantee for drugs that if they re safe, cost-effective and doctors say you need them, you will get them. From April 2013, for the first time ever, the Government is extending that guarantee to radiotherapy too. This has the potential to help thousands of people at one of the hardest times of their lives. 1.2 National commissioning of radiotherapy As of April 2013, radiotherapy is commissioned at a national level as a specialised service by NHS England. A new service specification for radiotherapy sets national standards for the service. It is expected that this specification will be fully implemented in October The specification, drafted by the NHS England Radiotherapy Clinical Reference Group, states that the following advanced radiotherapy should be available to all patients who might benefit in England: Intensity Modulated Radiotherapy (IMRT) uses complex physics to sculpt radiotherapy to give a high dose to the tumour while avoiding normal tissues. The accepted minimum standard is that inverse planned IMRT should be used in almost a quarter of patients treated with curative radiotherapy especially with head and neck, prostate, lung, and bladder cancer. Less complex forward planned IMRT is recommended for breast cancer patients. It is considered that at least 9% of all radical radiotherapy should be forward planned. Image Guided Radiotherapy (IGRT) imaging is carried out during treatment to check for tumour movement or change during therapy guaranteeing accuracy and allowing smaller volumes to be treated. IGRT should as a minimum be used in radical treatment for tumours that move with breathing or bowel function such as lung, prostate and bladder; in effect all thoracic and abdomino-pelvic treatment sites. Stereotactic Ablative Radiotherapy (SABR) this form of treatment is used to deliver a small number of very high dose treatments with curative intent where the treatment volume is small and defined. All patients with early lung cancer who are not suitable for surgery should receive SABR. SABR can be delivered by linear accelerators and other specially designed equipment. The RTDS is the national standard dataset for radiotherapy and is collected from radiotherapy treatment machines. Delivery of IMRT is measurable from the standard dataset. However, the coding currently does not allow a unique measurement of inverse planned IMRT. For this evaluation we have therefore had to rely on self-reported data from radiotherapy centres. 1.3 The need for the Radiotherapy Innovation Fund In 2009 the National Radiotherapy Implementation Group (NRIG), set up to advise and support the Department of Health in delivering a programme of work aimed at driving forward progress in radiotherapy in England, published guidance for commissioners on the use of IMRT. NRIG recommended that 33% of all radiotherapy should be delivered as IMRT, of which 24% should be the more complex inverse planned IMRT. The aim of the Fund was to ensure all centres reached the 24% level. Emerging evidence 8 in early 2012 indicated a wide variation in access to IMRT across radiotherapy centres in England. It was clear that some form of incentive was necessary to identify the range of causes and barriers to the delivery of IMRT, and associated IGRT, and to ensure more rapid progress 8 Mayles WPM, Cooper T, Mackay R, Staffurth J, Williams M. Intensity-Modulated Radiotherapy Implementation in the UK. Clin Oncol. 2012; 24:

10 towards higher quality and activity levels to make the service fit for practice by the time national commissioning was introduced. However, despite attempts to boost IMRT provision in recent years, at the end of 2012 levels in England fell well below acceptable standards, except in a handful of centres. In November 2012 the Department of Health report Radiotherapy Services in England 2012 concluded that although 100% of machines are IMRT capable, and IMRT is now offered in 48 of 50 centres, delivery at some centres was still 'unacceptably low'. Only 4 out of 50 radiotherapy centres in England were delivering inverse planned IMRT to at least 24% of their patients. Figures obtained both from the RTDS and a self reported survey of IMRT delivery conducted by Professor Sir Mike Richards showed that levels of IMRT across England during 2011/12 were on average 6.8%. Centres indicated that the average IMRT level for England was anticipated to rise to 15% by April Further self-reported figures in August 2012 showed an average of around 13.6% IMRT delivery across all centres in England. Centre level data on IMRT provision at August 2012 are detailed in Appendix 1. Levels of other types of advanced radiotherapy including IGRT and SABR also languish behind recommended standards. According to Department of Health figures, while all newly purchased machines are IGRT capable, only 40-50% of existing machines are utilising IGRT. 1.4 Incentives for advanced radiotherapy Various incentives have been introduced over the past four years aimed at increasing IMRT levels. In addition to NRIG guidance for commissioners, a draft business case on IMRT was developed to help providers make the case for funding to support increased delivery at a local level. Prior to this, most radiotherapy services were purchased by local commissioners on a block contract. This prevented the necessary extra service investment required to support the implementation and delivery of IMRT, which needs specific equipment and workforce skills development, and increased time for treatment planning and checking. The NHS Operating Framework for 2011 included a requirement that all cancer networks should have at least one centre delivering IMRT by April 2012, and stated that: to improve outcomes for radiotherapy treatment for cancer patients, commissioners should develop local plans to ensure that access rates to radiotherapy and the use of advanced radiotherapy techniques such as Intensity Modulated Radiotherapy, are appropriate for their populations. Central funding has also been provided for a number of training courses for planners and oncologists, supported by the professional bodies for radiotherapy. In 2011/12 an IMRT measure was included in locally agreed Commissioning for Quality and Innovation (CQUIN) goals. In 2012/13 an IGRT measure was included in locally agreed CQUIN goals. An IGRT roll-out programme was also supported during 2012/13 with guidance provided to departments by appointed IGRT leads and a training course. Alongside this, e-learning programmes were completed, commissioned and launched for advanced radiotherapy

11 1.5 Current barriers to advanced radiotherapy In August 2012 Professor Sir Mike Richards, then the National Clinical Director for Cancer, wrote to all radiotherapy centres in England asking them to outline their current radiotherapy provision. Those centres not delivering 24% inverse planned IMRT were asked to identify the blockages to reaching optimal levels of IMRT and prepare local action plans to address these. Responses varied between centres, but a few emerging themes were identified: No agreed tariff system incentive for advanced radiotherapy techniques to reimburse increased costs of delivery of IMRT or IGRT; Training needs, mainly in physics and oncology. In particular, gaps in the skills and availability of dosimetry staff to undertake IMRT; Vacant or frozen staff posts; Additional staff time needed for IMRT planning (as the process per patient is significantly longer than conventional planning); A need for additional workstations to compensate for additional time taken to plan advanced radiotherapy; The need for additional planning licenses; Limited linac capacity and/or the ability of older machines to deliver advanced radiotherapy; For some centres the issue was that local commissioners wouldn t agree to support the additional costs required to allow IMRT delivery. Tariffs were not amended, therefore some centres were left unable to progress or had to cut back in another area to push forward with IMRT. Others were fortunate that the initial locally agreed tariff for radiotherapy was set so that it supported this. One centre reported that a lack of confirmed income has meant that plans to grow infrastructure had to be put on hold. 11

12 2 Detail and aim of the Fund On the 6 th October 2012, the Prime Minister announced a 15million Radiotherapy Innovation Fund. This revenue fund was available for the remainder of 2012/13, primarily aimed at extending NHS capacity to deliver IMRT so that all appropriate cancer patients might benefit from April Revenue vs. capital funding The Fund was provided as a revenue fund through the Department of Health. Due to the time limited nature of this Fund the Department asked centres to ensure that requests did not precommit NHS England to future funding. As such the Fund was not intended to provide for additional linear accelerators or new staffing posts, as long term sustainability of advanced radiotherapy should be addressed as part of Trusts routine business planning. Trusts were instead encouraged to buy technology or devices that enhanced the capability of existing equipment. An intensive support team led by the National Cancer Action Team held challenge visits with all centres not meeting the required levels of IMRT. These visits were used to challenge funding applications and assist local teams in developing business cases for additional equipment falling outside the scope of the Fund. A list of potential items or use of revenue funding provided to centres is attached in Appendix Implementing the Fund The Fund was made available as part of a programme of work aimed at directly supporting the radiotherapy service. This programme comprised two key elements: 1 The 15 million Radiotherapy Innovation Fund. 2 A programme of visits to radiotherapy centres failing to meet 24% inverse planned IMRT. While the Fund was introduced with the intention of improving access to advanced radiotherapy as a whole, it was agreed that the priority in the first instance was to bring capacity for IMRT up to the agreed standard. To support the Fund, central resources also provided funding for three bespoke training courses: one for clinical oncology staff; one for physics/dosimetrist staff, detailing introductory principles of IMRT; and a third course on IGRT, tailored to radiographers and physics IGRT leads from all English centres as part of the IGRT programme. These courses were led by the National Cancer Action team and professional bodies, and were delivered between January and June Details and evaluation of these training courses are provided in Appendix 6. Alongside this, and also outside the remit of what was provided by the Fund, e-learning programmes were completed, commissioned and launched for advanced radiotherapy 10. A core group chaired by Cancer Research UK and comprising members from the Department of Health, the National Cancer Action Team, the National Radiotherapy Implementation Group (NRIG), the Royal College of Radiologists, the Society and College of Radiographers and the Institute for Physics and Engineering in Medicine was established to oversee the allocation of the Fund. This group was supported by clinical expertise from NRIG members based at centres with good levels of IMRT delivery

13 It was agreed that each radiotherapy centre in England should have access to 150,000 of revenue funding, as long as it could set out how it could use it appropriately. However, to ensure that the Fund could respond to areas of the greatest need and greatest opportunity for improvements to IMRT, the remainder of the Fund was allocated against individual applications for additional funding. If a centre had already achieved the appropriate level of IMRT it was agreed that these centres could use the funding to support the adoption of other technical advances in radiotherapy including IGRT. The methodology applied to distribute the Fund is detailed in Appendix 2 and Request for additional funding As applications were received from the service and challenge visits held at 46 centres around the country during November and early December 2012, it became clear that the original 15million would be unlikely to match the demand for clinically appropriate service improvements. A scoring and prioritisation process was introduced to allow the core group to rank requested items according to need and opportunity to boost IMRT delivery (please refer to appendix 4). However, at the end of this process, the core group was still faced with the prospect of rejecting around 8million of clinically appropriate, much needed, additional funding requests which could make a real difference to advanced radiotherapy provision. In December 2012 a request was put to the Minister for Health to make additional funding available. On 18 th December Health Minister Dan Poulter announced in Parliament that the Fund would be boosted from 15 to 23million. This additional funding meant that, in the majority of cases, the Fund was able to provide for most or all of the items requested by centres. It is worth reflecting that although centres were invited to be ambitious with their funding requests, it was clear from the applications received that the majority of centres were conscious of the financially limited nature of the Fund. The resulting bids were therefore not an accurate picture of the scale of the need for additional funding across the service, but closely prioritised and focused on the challenge of delivering IMRT. 13

14 % IMRT Prior to the Fund 3 How the Fund was allocated 3.1 Distribution by level of IMRT Figure 1 shows allocations for 50 radiotherapy centres according to the level (%) of inverse planned IMRT they were delivering at the outset of the programme. One London based centre submitted a bid of over 4million (this was due to the centre bidding for linac replacement, which was outside the scope of the Fund). The next highest bid was for just under 1m. For the purposes of the calculations below, the 4million bid from the single London centre is considered an outlier. Figure 1 demonstrates that the amount of funding requested by centres varied greatly, and bore little relation to the amount of IMRT they were delivering at the time. It is also useful in demonstrating the success of the Fund, in delivering most centres with the funding that had been requested. Figure 1 14

15 A strict prioritisation process was put in place to assess bids, as follows (please refer to Appendix 4 for more details): Bids from Trusts with the lowest reported IMRT activity levels and robust proposals for delivering from April 2013 were prioritised first. Bids from Trusts making sound proposals to deliver above the 24% level. Bids that support increased capability to deliver using Image Guided Radiotherapy (IGRT). Bids from Trusts making robust proposals for other advanced techniques that would directly benefit patients. Figure 1 above demonstrates that, from the original 15million Fund, bids from Trusts with the lowest reported IMRT levels were prioritised first. However, consideration was also given to whether these lower performing Trusts were in a position to make best use of all requested new equipment, particularly in terms of existing staff capacity or expertise within the Trust. This is why better performing Trusts (those delivering between 7-17% IMRT) tended to do better out of the second round of funding, once the additional 8million had been announced. In general lower performing centres submitted higher funding requests, as seen in Table 1. Table 1 Average bid size Lowest request Highest requested 0<12% 544, , ,188 12<24% (with outlier) 787, ,700 4,630,749 12<24% (without outlier) 467, , ,632 24%+ 443, , ,200 n.b. total bid > 4m 15

16 3.2 Regional spread of IMRT delivery and bid requests. Table 2 outlines the distribution of funding by region. No clear correlation can be seen between average IMRT delivery and the size of the bids. Table 2 Region Lowest IMRT (%) Highest IMRT (%) Average IMRT (%) at the outset of the programme Lowest request Highest request Average bid size South West , , ,491 South East , , ,673 South Central , , ,918 Yorkshire and Humber , , ,997 East Midlands , , ,100 North West , , ,524 North East , , ,899 East of England , , ,999 West Midlands , , ,980 London (with outlier) London (without outlier) ,000 4,630, , , , ,642 16

17 3.3 Items requested from the Fund Figure 2 outlines how the Fund was spent. Linac upgrades, advanced treatment planning and IMRT Quality Assurance (QA) made up around three quarters of funded bids. While making up a small proportion of the overall Fund, training and temporary agency staff/additional payments on a temporary basis for staffing were requested by most centres. This supported additional commissioning and training only. Figure 2 17

18 Table 3 outlines regional average spend on different types of equipment. IMRT delivery in a specific region does not appear to correlate to a particular average spend on pieces of equipment. This suggests that centres within each region have approached the challenge of delivering advanced radiotherapy differently because of different local challenges. Table 3 Average IMRT in August (%) Advanced treatment planning IMRT/IGRT QA IGRT equipment Linac upgrades Training Staffing Region South West ,563 98, , ,521 22,100 75,502 South East ,288 36, , ,790 41,400 33,925 South Central ,929 61, , ,920 25,125 46,270 Yorkshire and Humber ,913 62, , ,650 7,000 89,100 East Midlands ,245 52, , ,975 5,250 31,717 North West ,955 38, ,318 92,497 7,162 84,414 North East ,700 14, ,000 20,640 48,000 East of England , ,746 10,000 60,480 16,958 50,154 West Midlands , , , ,790 6,800 5,000 London ,728 68,368 83, ,095 19,575 33,232 18

19 Advanced treatment planning Requests for advanced treatment planning systems were fairly consistent across all centres. These systems on the whole were requested to improve productivity, increasing available planning capacity and maintaining quality, even for centres meeting the minimum standard for IMRT. Requests for additional planning workstations by all centres should result in an increase in the delivery of IMRT in all centres, even the ones currently delivering at 24% or above. Figure 3 shows the amount of funding provided for advanced treatment planning for each centre. Figure 3 % IMRT prior to the Fund Quality Assurance (QA) equipment Fewer centres requested QA equipment. Those that did varied greatly in the amount of IMRT they delivered. 30 centres requested less than 50,000 of IMRT/IGRT QA equipment. Figure 4 shows the amount of funding provided for IMRT/IGRT QA for each centre. Figure 4 % IMRT prior to the Fund 19

20 IGRT equipment Centres with established plans to deliver the required amount of IMRT were approved for funding for IGRT equipment. Centres delivering less than 24% that demonstrated they would be able to deliver the amount of inverse planned IMRT while also improving IGRT provisions were granted funding. IGRT equipment tended to be funded out of the additional 8million provided to the Fund. Figure 5 shows the amount of funding provided for IGRT equipment for each centre. Figure 5 % IMRT prior to the Fund 20

21 Linac upgrades Linac upgrades in general were less frequently requested than other major pieces of equipment, mostly as the Fund could only deliver revenue and not capital costs. Most upgrades requested were for rotational IMRT aimed at speeding up the delivery of IMRT. Figure 6 shows the amount of funding provided for linac upgrade for each centre. Some centres requested upgrades that extended the life of their existing machines. However, this is a temporary solution and further capital plans within the Trusts need to be put in place to ensure that advanced radiotherapy is delivered effectively in the future. Figure 6 % IMRT prior to the Fund 21

22 Training costs Training requests for specific local training within the centres were in addition to the IMRT and IGRT courses funded by Department of Health, led by the NCAT and professional bodies (Appendix 6). The vast majority of training requests came from centres that were delivering less than 15% IMRT. It is possible that centres already beginning to deliver IMRT at a low level required further training of a number of their staff in order to ramp up delivery effectively and efficiently. Figure 7 shows the amount of funding provided for training for each centre. Figure 7 % IMRT prior to the Fund 22

23 Staffing costs Requests for additional short term staffing costs came exclusively from centres delivering below 24% IMRT. Typically, staff time was used so that centres could commission equipment. This suggests that existing workforce did not have the capacity to adopt new technologies without being funded to work additional hours; the Fund offered this short term solution. Many of the centres indicated a need for an overall increase in staff posts, but the Fund was unable to support this due to its timelimited nature. The additional hours of overtime payment for staff time provided by the Fund should give lower performing centres the ability to overcome these equipment commissioning barriers and deliver higher levels of IMRT. However, some centres will require a permanent increase in staff posts to enable increased capacity for IMRT treatment planning on a long term basis. Figure 8 shows the amount of funding provided for staffing costs for each centre. Figure 8 % IMRT prior to the Fund 23

24 4 Impact of the Fund Since the introduction of the Radiotherapy Innovation Fund in October 2012 there has been a step change in the provision of the IMRT component of advanced radiotherapy across England. In August 2012, % of patients receiving radiotherapy in England were given IMRT. By April 2013 this figure had risen to 22.3% Number of patients likely to benefit The Department of Health estimated that if centres can increase their capability to 24% IMRT, a further 8,000 patients would benefit 13. The self-reported figures we are reporting indicate that, with the increase to 22.3% in April 2013, around 5,800 more patients across England a year will now have access to advanced radiotherapy treatment. While not all centres reached the target levels of IMRT by April 2013, the majority of centres are well on their way to achieving this and the number of centres exceeding 24% IMRT has grown. Experts now consider that centres should be going beyond the 24% target, with the optimal level of IMRT delivery more likely to be around 50% of radical patients 14. This means that there is potentially scope for thousands more patients to benefit annually from advanced radiotherapy. 4.2 Increase in IMRT delivery Over a very short period of time, this programme of work and the associated Fund has achieved an uplift of nearly 9 % inverse planned IMRT delivery across England. This has exceeded previous expectations of the centres, which were that the average provision of IMRT would hit 14% on average by April , way below the 22.3% achieved. This clearly demonstrates the value the Fund has brought in achieving a substantial increase in inverse planned IMRT delivery. In addition, the delivery of IMRT overall (inverse and forward planned) has significantly increased since the launch of the Fund, as shown by RTDS data detailed in Appendix 1. Position as of April 2013 Case study from Royal Berkshire Cancer Centre In October when the Radiotherapy Innovation Fund was announced, Berkshire Cancer Centre (BCC) was treating 8% of radical courses using inverse planned IMRT. While the Fund was a very welcome boost to resources, the allocation of funding was not announced until late December 2012, which presented challenges in relation to the purchase and commissioning of equipment. However, the additional physics capacity that has been achieved has enabled BCC to be in a position, where, at the end of April it was treating 17% of radical courses using inverse planned IMRT with an estimated trajectory of treating 24% of patients by the end June A self-reported position was obtained from individual centres. This showed average delivery in April of 22.3% inverse planned IMRT across all centres. 22 centres out of 50 are now delivering at or 11 Data for 4 centres was only available for November 2012 (prior to the implementation of the fund) and has been assumed to be representative of IMRT delivery at those centres at this point in time. 12 Based on self-reported proportions of radically treated patients receiving inverse planned IMRT in these periods, and the number of radically treated radiotherapy patients in FY 2012/2013 at each of the centres in England T. Cooper, M.V. Williams. Implementation of Intensity-modulated Radiotherapy: Lessons Learned and Implications for the Future. Clinical Oncology 24 (2012) Department of Health (2012). Radiotherapy services in England

25 above 24% inverse planned IMRT. A breakdown of self-reported IMRT delivery by centre can be seen in Appendix 1. Table 4 shows the average increase in IMRT delivery between August 2012 and April 2013 by region (ordered by average delivery of IMRT in April 2013, from lowest to highest). Table 4 Region Average funding allocated Total funding allocated Average IMRT (%) at the outset of the programme Average IMRT (%) April 2013 South West 444,920 3,114, South East 536,673 1,610, South Central 539,125 3,234, East Midlands Yorkshire and Humber North West 483,986 3,387, ,997 1,898, ,302 1,817, West Midlands 363,980 1,455, East of England 397,581 2,783, London 309,133 2,783, North East 220, , While data from the Radiotherapy Dataset (RTDS) will be used to report progress going forward, we are not able to report data from the April collection of the RTDS in this evaluation. This is because some centres are reporting Quality Assurance for forward planned treatments within the IMRT code as well as inverse planned IMRT. The former was not the focus of the Fund and so would provide an artificially high level of inverse planned IMRT for some providers. The centres self-reported levels of inverse IMRT as of April are the most up to date indication of current levels available. These data have been rigorously reviewed and checked. There are obvious limitations to self-reported data and while Appendix 1 gives an outline of centre performance, it is still possible that there are some inaccuracies in the data. We therefore have recommended that there should be more granularity in the coding and reporting of advanced radiotherapy in the RTDS to allow for more rigorous monitoring of inverse planned IMRT. Post-April 2013 A letter sent from the Department of Health to Health Minister Anna Soubry in late 2012 stated that With the funding announced by the Prime Minister and based on centres plans, from April 2013, 35 centres will be delivering at or very close to 24%. By the end of 2013, 44 centres will be delivering at 24% with the remaining 6 reaching 24% early in

26 While this report outlines that these predictions have not been met, with 22 meeting the 24% target by April, many of the benefits have not yet been seen due to lead in time to use some of the resources provided by the Fund. Much progress has been made, with a further 17 centres delivering at 15% and over. Hopefully this upward trend will mean all centres are delivering 24% before the start of Case Study from Royal Cornwall Hospital Royal Cornwall Hospital Trust (RCHT) received its first IMRT capable linear accelerator in August 2012 and therefore could not offer IMRT to patients prior to this time. The process of the Fund largely overlapped the centre s efforts to bring the machine online and incorporate IMRT into their workflow. The Fund assisted with this as it allowed RCHT to pay for two temporary band 7 radiographers to enable additional training of existing staff on the linac capable of IMRT, which enabled the department to extend the working day on the linac and therefore increase the capacity for IMRT. In the first months of 2013 the RCHT exceeded its expected delivery of IMRT resulting in 17% delivery in April. The provision of additional equipment and software through the Fund had not further enhanced the volume of IMRT by June This is primarily as commissioning of the equipment, which is underway must be completed before clinical use and considerable additional staffing resources are required to support the planning of IMRT patients. RCHT has identified two significant challenges. Firstly that the centre only has a single IMRT capable linac with no realistic backup plan should this one fail. Secondly the Trust lacks sufficient consultant capacity (and support including radiographers) to support, plan and deliver increasing volumes of IMRT alongside overall delivery of its cancer services. The Trust has recently approved a significant three phase investment in additional staffing. The first tranche of this investment is being advertised immediately. Prior to the Fund, the RCHT s estimated date for 24% IMRT was December However, once the equipment has been fully commissioned, it is expected that this date will be brought forward to the autumn of 2013 or earlier. 26

27 5 Additional benefits from the Fund There have been a number of additional benefits to this programme of work that will likely contribute to further improvement of the radiotherapy service in the longer term. 5.1 Galvanising the radiotherapy community One of the requirements of application for the Fund was that all centres either not meeting or not well on their way to meeting the required 24% IMRT should have a challenge visit from an NCAT led intensive support team. These sessions were confidential discussions between clinical members identified by the Fund s core group plus additional expertise in physics, led by the NCAT Associate Director for Radiotherapy, and a team from each centre which was representative of the specialities across the radiotherapy department. In total 46 visits were held in November and early December These sessions were aimed at ensuring that funding requests were clinically justified and appropriate. They also provided an opportunity to discuss local barriers, check reported and rampup figures, and ask often challenging questions where progress in developing advanced radiotherapy had been slow to date. The clinical teams were also tasked with directly challenging funding requests, asking centres to justify equipment requests and explain why these could not be provided for within local commissioning or other arrangements with their Trust. These sessions differed from other mentoring opportunities offered by NCAT for several reasons: 1. Senior level engagement: The financial imperative of the Fund meant that these sessions were well attended by senior NHS Trust board level radiotherapy staff. On a number of occasions centre representatives were joined by members of the Trust executive and finance teams with whom it has traditionally been difficult for departments to engage. 2. Challenge to existing practice: As they followed a self-reported survey of IMRT provision, the visits provided an opportunity for an honest conversation about progress in introducing advanced radiotherapy and possible cultural or organisational barriers which would need addressing in concert with additional equipment or staff training. 3. Asking centres to submit a ramp up plan for IMRT: This helped focus the minds of centres on the size of the challenge facing them and consider why, when increases in actual numbers were small month-on-month, this was not happening already. 4. Highlighting inaccuracies in reporting: Challenge visits provided an opportunity to compare self-reported activity to that captured in the RTDS, explore reasons for differences and reiterate the importance of accurate data collection. These sessions are thought to be largely responsible for the significant ramp up in IMRT provision across the country in line with self-reported predictions, even before additional purchased equipment or training had hit the ground. 5.2 Improving senior Trust-level engagement Failure of Trusts to commit to long term plans, and the difficulty of getting purchasing approval for large capital items were cited amongst the barriers to IMRT delivery in response to Professor Sir Mike Richards August 2012 survey of the service. A lack of engagement by senior Trust figures was thought to be a significant contributory factor. 27

28 The core group recognised the Fund as an opportunity to directly address this. Letters sent from Professor Sir Mike Richards on behalf of the Department of Health, announcing the Fund and outlining plans for its distribution were sent directly to Trust Chief Executives. This letter also asked Trusts to identify the appropriate clinical teams at each centre and encourage them to attend the one-day training events held in support of the Fund. All funding requests required senior Trust level sign off before submission. This engagement served to underline the priority of radiotherapy within their organisations. This was particularly important in non cancer specialist Trusts. Chief Executives received a letter on 21st December 2012 confirming the funding allocation awarded to their centre. 5.3 Procurement through NHS Supply Chain NHS Supply Chain, working as an agent on behalf of the NHS Business Service Authority and the Department of Health, engaged in this programme of work to ensure the maximum benefit was realised from the Fund. This was achieved by aggregating national demand, effectively ensuring the buying power of 50 centres was levered to each individual centre while retaining local choice. Of the 15 million that was procured via NHS Supply Chain, over 2 million (13%) in savings was delivered back to the NHS. In real terms, this meant that centres were able to procure additional equipment from the Fund, to enhance their ability to deliver to the 24% level. NHS Supply Chain worked with every centre and across the key stakeholders to ensure the processing of orders was kept on time, and facilitated the required engagement with suppliers to ensure delivery to timescales was supported. NHS Trusts were assured that by having National Framework Agreements already in place there was a compliant route to procure under EU Public Procurement regulations, minimising the risk of challenge on this Fund and greatly reducing the procurement timescale. While the maximum benefit was derived from the Fund within the time restrictions in place, a key learning was the ability to forward commit to suppliers to ensure the ongoing sustainability of savings available to the NHS. NHS Trusts should work with NHS Supply Chain to make full use of the 300 million capital equipment fund. A national programme of asset management for radiotherapy equipment could be considered to facilitate commitment deals in the market to drive sustainable savings for NHS procurement of capital equipment. 28

29 6 Remaining challenges for the NHS in provision of advanced radiotherapy Significant challenges remain if the service is to meet the Prime Minister s ambition that all patients will get access to all clinically appropriate, cost effective, radiotherapy which their doctor recommends. 6.1 Boosting advanced radiotherapy capacity The Department of Health has recognised that while the National Radiotherapy Implementation Group (NRIG) recommended that 24% of patients should receive IMRT as part of their treatment, this is the minimum standard and the true rate for delivery of IMRT is likely to reach approximately 50% of radical radiotherapy patients over the next few years. It is also worth remembering that IMRT is only one component of advanced radiotherapy. NRIG and now the NHS England Radiotherapy Clinical Reference Group both recognise that a significant number of patients should also be getting access to 4D adaptive radiotherapy including Image Guided Radiotherapy (IGRT) and Stereotactic Ablative Radiotherapy (SABR). Although exact figures on delivery of these treatments in England are not available at this time, it is thought that delivery lags well behind recommended levels. NRIG recommendations state that all patients who are getting IMRT should be offered some form of IGRT. This would ensure that the available technologies are used to deliver appropriate radiotherapy doses to complex shaped tumour targets within the body (to maximise cure rates), minimise the doses to normal tissues, and ensure that changes of the tumour target with time are measured and patient factors such as daily variation in positioning and internal organ motion (such as breathing) are taken into account. Commissioning guidance from NHS England recommends that all patients with non-resectable lung cancer should be offered SABR. A concerted effort will be needed to ensure that these technologies are rolled out across the country over the coming months ensuring equity of access and high quality treatments for patients. There is concern that ongoing capacity issues within the service, both in terms of adequate workforce within centres to meet the increasing demands of more complex planning and treatment as well as lack of capital equipment, may prevent some centres from meeting these targets. In addition, in April 2012 the Secretary of State for Health announced that the Department of Health had set aside up to 250 million of public capital to be invested by the NHS in building Proton Beam Therapy facilities at The Christie Hospital in Manchester and University College London Hospital to treat up to 1500 patients every year in this country. The first facility will become operational from the end of While this is welcome progress, introducing proton therapy into the UK will put additional pressure on an already stretched radiotherapy workforce. The Department of Health has recommended that detailed workforce planning for the whole radiotherapy workforce (clinical oncologists, therapeutic radiographers and medical physicists) will be required to ensure there is sufficient workforce to meet current and future service needs. This needs to be addressed as a matter of urgency. 6.2 Change of currency for IMRT fractions (i.e. number of treatments) to patients The currency for measuring the delivery of advanced radiotherapy has recently changed from the total number of treatments delivered with IMRT per patient (i.e. number of fractions) to the number of patients receiving IMRT. This change was made to provide a more consistent measure to 29

30 accurately assess the treatment patients are receiving. It was assumed, perhaps erroneously, that the percentage of fractions directly equates to the same percentage of patients treated. However, this is not the case in all centres. For example, Nottingham University Hospitals NHS Trust exceeded 24% significantly by treating 31% of radical fractions with inverse planned IMRT in quarter 4 of 2012/13. However, this equated to only 22% of the number of patients treated radically. Whilst services were informed of the change of currency through Radiotherapy Innovation Fund meetings and letters, this process happened at the same time as services were striving to achieve the fraction target for the CQUIN. It is therefore possible that many more services have achieved the original currency target of 24% fractions than are now able to comply with the corresponding 24% of patients. Further work remains to ensure that the IMRT code in the RTDS reflects all patients treated with inverse planned IMRT and does not include forward planned IMRT QA data. 6.3 Additional challenges in radiotherapy In addition to the above challenges radiotherapy centres identified a number of issues which could not be addressed by the Fund, either because these require systemic changes or because they lie outside the scope of the Fund. These were highlighted by centres in their applications to the Fund. Many of these issues, which impact on the ability to deliver advanced radiotherapy, are well known and were reflected in the recent Department of Health report Radiotherapy Services in England The size of the challenge and possible impact are outlined below More patients need to be treated with radiotherapy The Department of Health reported that by 2016 a 67% increase in current activity will be needed. 16,17 Although experts recommend that half of all cancer patients should have radiotherapy as part of their treatment, in England it is thought that this level remains at around 40%. This could be attributed to a variety of factors. For example, a lack of advanced radiotherapy capacity could be deterring clinicians from recommending patients for radiotherapy. Improving advanced radiotherapy and further promoting the benefits of radiotherapy services to clinicians and patients is likely to drive take up of this important, and highly cost effective, treatment There are not enough linear accelerators and many are out of date As seen in Figure 9, there are currently 270 linacs in operation in England. The Department of Health reported that increases in demand mean that this figure will need to be 412 by To ensure appropriate radiotherapy capability and the latest techniques are available, existing machines need to be replaced at 10 years. Of the current linacs, 48 are over 10 years old and should be replaced. An additional 64 will be over 10 years old by In total, the NHS therefore needs an additional 254 new linacs over the next three years. Responsibility for replacing and investing in new machines lies at the Trust level. 16 Population growth and ageing are driving an increase demand for radiotherapy of 2.3% per year ,000 attendances per million population (pmp) in 2010/11 versus the Malthus target of 55,000 pmp in Department of Health (2012). Radiotherapy services in England

31 The Department of Health has established a 300 million fund to encourage the NHS to update the existing medical technology infrastructure, operated by NHS Supply Chain. The NHS Operating Framework 2012/13 published in November 2011 included a comply or explain provision aimed at NHS Trusts. However, the scale of the current shortfall suggests that, to ensure that the service is adequately resourced to meet patient need over the next four years, this is no longer a practical solution and additional support may be required. Figure 9 19 Responses to Professor Richards survey in August 2012 highlighted a number of centres where the age of linacs was inhibiting progress in advanced radiotherapy. Not only are there challenges in making a business case for upgrading a machine that has only a few years of useful service left, but older machine treatment times are slower. They therefore take up treatment slots which impactd on throughput and consequently waiting times for patients, deterring the service from introducing newer techniques. It is the responsibility of Trusts to provide equipment to deliver safe and effective radiotherapy to match the national service specification. The following initiatives may help: a. The CQUIN for IGRT for the year 2013/2014; b. The new national tariff for advanced radiotherapy as the driver to clearly cover the higher complexity and costs of IMRT and IGRT; c. NHS Supply Chain will have a mechanism to ensure best prices are available and access to 300 million equipment fund Staffing and training remain key issues Increasing demand on the radiotherapy service means that increases in staff numbers are needed in all areas of the radiotherapy workforce. All centres will need to review and, where necessary, remodel the workforce structure to capitalise on technological advancement and make effective use of the skilled workforce across the service. Mapping of workforce requirements (numbers, skills and 19 Radiotherapy Clinical Information Group Quarterly Report to Cancer Programme Board Q3 31